On Monday, the state of North Carolina agreed to a $2.5 million settlement with the estate of Michael Anthony Kerr, who died in March 2014 after spending two months in solitary confinement at Alexander Correctional Institution.

“A finding of liability is inevitable,” according to a May 6 memo by Special Deputy Attorney General Amar Majmundar. “Mr. Kerr’s death was the direct result of multiple, flagrant errors committed by various Alexander Correctional staff members.”

The memo, first reported by WRAL-TV of Raleigh, noted that Kerr had a well-established history of mental illness, including major depression after the murder of two of his sons. Kerr had been convicted of firing a gun into an occupied dwelling that he apparently believed was connected to the second murder.

The memo suggests that prison officials deprived Kerr of his psychiatric medicine after he was placed in solitary confinement as a disciplinary measure in January 2014.

Michael Anthony Kerr, 54, was found unresponsive in the back of the van March 12 after being driven roughly three hours from Alexander Correctional Institution in Taylorsville to a mental hospital at Central Prison in Raleigh.

The North Carolina Department of Public Safety subsequently fired a captain and four nurses at Alexander. A nurse and a staff psychologist resigned.